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Summary

A needs-led approach to mental healthcare

A needs-led approach to the provision of mental healthcare has been one of the most consistent themes to emerge within evolving community mental healthcare services. In England this was first expressed in the provisions of the National Health Service and Community Care Act 1990. The central tenet of a needs-led approach is that assessment of the needs of patients should be on the basis of their individual circumstances, problems and personal goals. Assessment should not be undertaken in terms of or on the basis of existing services, that is, assessment should not be service based. This means that assessment of need is a separate process from decisions about what care or treatment to provide.

Needs-led assessment should, for example, look at whether people have access to enough activities which are meaningful (to them) each day, rather than whether they need to attend a day centre. If the assessment indicates that there is a problem with daytime activities, one service response might be a place at a day centre. Another, however, might be support in undertaking voluntary work. Needs-led assessments have two advantages over service-based assessments: first, they point to the most appropriate form of service response (in terms of treatment or care) for the individual's difficulties; and second, they have the potential to indicate needs for which there is currently no service provision, which a service-based assessment by definition would not identify.

What is a need?

People with severe mental illness usually have a wide range of clinical and social needs. A variety of approaches to defining need have been proposed. The American psychologist Maslow (1954) established a hierarchy of need when attempting to formulate a theory of human motivation. In Maslow's model, fundamental physiological needs (such as the need for food) underpin the higher needs of safety, love, self-esteem and self-actualisation. He proposed that people are motivated by the requirement to meet these needs, and that higher needs could be met only after the lower and more fundamental needs were met. This approach can be illustrated by the example of a homeless man, who is not concerned about his lack of friends while he is cold and hungry. However, once these physiological needs have been met he may express more interest in having the company of other people.

States have established public reporting of hospital-associated (HA) infections—including those of methicillin-resistant Staphylococcus aureus (MRSA)—but do not account for hospital case mix or postdischarge events

A retrospective cohort study of 2009–2010 California acute care hospitals. We defined HA-MRSA admissions as involving MRSA pneumonia or septicemia events arising during hospitalization or within 30 days after discharge. We used mandatory hospitalization and US Census data sets to generate hospital population characteristics by summarizing across admissions. Facility-level factors associated with hospitals’ proportions of HA-MRSA infection admissions were identified using generalized linear models. Using state methodology, hospitals were categorized into 3 tiers of HA-MRSA infection prevention performance, using raw and adjusted values.

Results.

Among 323 hospitals, a median of 16 HA-MRSA infections (range, 0–102) per 10,000 admissions was found. Hospitals serving a greater proportion of patients who had serious comorbidities, were from low-education zip codes, and were discharged to locations other than home were associated with higher HA-MRSA infection risk. Total concordance between all raw and adjusted hospital rankings was 0.45 (95% confidence interval, 0.40–0.51). Among 53 community hospitals in the poor-performance category, more than 20% moved into the average-performance category after adjustment. Similarly, among 71 hospitals in the superior-performance category, half moved into the average-performance category after adjustment.

Summary

This chapter focuses on three entities namely disseminated intravascular coagulation (DIC), HELLP syndrome, and thrombotic thrombocytopenic purpura (TTP), which represents unique and critical threats to the well-being of mother and fetus during peripartum period. It is concerned with the etiology, clinical features, diagnostic methods and management of these entities. In non-bleeding patients with DIC, platelets and factor replacement should not be administered prophylactically or based on laboratory tests alone. The treatment of HELLP involves monitoring and responding to maternal signs and symptoms, particularly when pre-eclampsia is present, and includes fluid management and the use of antihypertensive agents and magnesium sulfate for seizure prophylaxis. Plasma exchange is the treatment of choice for TTP. The optimal treatment regimen for obstetric coagulation disorders continues to evolve, given the frequently dynamic clinical situation, the presence and health of the fetus, and a growing interest in conducting investigations during the peripartum period.

By
Mike Slade, Reader in Health Services Research at the Institute of Psychiatry, King's College London, UK,
Sonia Johnson, Professor of Social and Community Psychiatry, Department of Mental Health Sciences, University College London, and Camden and Islington NHS Foundation Trust, London, UK,
Michael Phelan, Consultant Psychiatrist, West London Mental Health NHS Trust, London, UK,
Graham Thornicroft, Professor of Community Psychiatry, Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK

Summary

A needs-led approach to mental healthcare

A needs-led approach to the provision of mental healthcare has been one of the most consistent themes to emerge within evolving community mental healthcare services. In England this was first expressed in the provisions of the National Health Service and Community Care Act 1990. The central tenet of a needs-led approach is that assessment of the needs of patients should be on the basis of their individual circumstances, problems and personal goals. Assessment should not be undertaken in terms of or on the basis of existing services, that is, assessment should not be service based. This means that assessment of need is a separate process from decisions about what care or treatment to provide.

Needs-led assessment should, for example, look at whether people have access to enough activities which are meaningful (to them) each day, rather than whether they need to attend a day centre. If the assessment indicates that there is a problem with daytime activities, one service response might be a place at a day centre. Another, however, might be support in undertaking voluntary work. Needs-led assessments have two advantages over service-based assessments: first, they point to the most appropriate form of service response (in terms of treatment or care) for the individual's difficulties; and second, they have the potential to indicate needs for which there is currently no service provision, which a service-based assessment by definition would not identify.

What is a need?

People with severe mental illness usually have a wide range of clinical and social needs. A variety of approaches to defining need have been proposed. The American psychologist Maslow (1954) established a hierarchy of need when attempting to formulate a theory of human motivation. In Maslow's model, fundamental physiological needs (such as the need for food) underpin the higher needs of safety, love, self-esteem and self-actualisation. He proposed that people are motivated by the requirement to meet these needs, and that higher needs could be met only after the lower and more fundamental needs were met. This approach can be illustrated by the example of a homeless man, who is not concerned about his lack of friends while he is cold and hungry. However, once these physiological needs have been met he may express more interest in having the company of other people.

A good medical history is an essential starting point in ensuring that the
physical health needs of people with severe mental illness are addressed.
Psychiatrists have an important role in helping to tackle the general ill
health, excess of undiagnosed physical illness and reduced survival rates
among their patients. To do this they need to use their medical training,
communication skills and regular contact with patients. Assessments should
include family history, past and current physical health, medication,
lifestyle, healthcare and physical symptoms. Some groups of patients will
need more detailed assessments.

The aim of this study was to describe the extent and variations in administration of depot antipsychotic medication within primary care in the North Thames Region, by means of a cross-sectional survey of a sample of general practices in the North Thames Region. Outcome measures were the number of patients receiving depot at the general practice, the professionals administering depot in that general practice, and the perceived need by these professionals for further training. Depot antipsychotic medication was administered in 55 practices (79.7% of the respondents). Practice nurses gave depot antipsychotics in 41 (59.4%) of the respondents, general practitioners in 27 (39.1%) of the respondents and community psychiatric nurses (CPNs) in 31 (44.9%) of the respondents in the practices studied. It was found that the majority of GP practices within the North Thames Region administer depot antipsychotic medication, and the GPs and practice nurses share a significant proportion of this administration. Practice nurses need specific training for this task, with access to regular refresher courses to ensure good practice.

The aim of this study was to examine visual problems among patients admitted to an inner city acute mental health unit. We measured visual acuity using a Snellen chart. Patients were also asked about perceived eye problems and access to services.

Results

Of 55 in-patients on five acute general adult wards at an inner city mental health unit over a 3-day period, 31 agreed to participate in the study. Twenty (65%) had impaired visual acuity and 19 (61%) had not been to an optician for 5 or more years. Seventeen patients (55%) reported experiencing difficulty with their eyesight. The main problems reported were blurring of vision and periorbital pain. Of these 17 patients, 15 (88%) had impaired visual acuity on Snellen testing. Half of those who had previously been prescribed glasses or contact lenses reported that they had been lost.

Clinical Implications

Visual impairment appears to be another area of physical health which is underrecognised and undertreated in people with severe mental health problems. Although there are numerous issues that must be addressed by mental health staff, patients should be asked about eye problems and supported in accessing opticians.

A prospective descriptive study was set up to evaluate the feasibility, acceptability and activity of an innovative weekly primary care service for patients admitted for acute psychiatric care.

Results

During 10 months, 36 clinics were held and 123 appointments were attended. Presenting complaints included a wide range of acute and chronic conditions, affecting all body systems. As well as treating specific complaints, the doctor providing this service undertook considerable health promotion work and gave advice about patient management to junior psychiatrists.

Clinical Implications

It appears that there is considerable need for primary care expertise within an acute psychiatric unit, and that a weekly clinic is a feasible model of care.

As the most prominent German-Jewish Romantic writer, Heinrich Heine (1797-1856) became a focal point for much of the tension generated by the Jewish assimilation to German culture in a time marked bya growing emphasis on the shared ancestry of the German Volk. As both an ingenious composer of Romantic verse and the originator of modernist German prose, he defied nationalist-Romantic concepts of creative genius that grounded German greatness in an idealist tradition of Dichter und Denker. And as a brash, often reckless champion of freedom and social justice, he challenged not only the reactionary ruling powers of Restoration Germany but also the incipient nationalist ideology that would have fateful consequences for the new Germany--consequences he often portended with a prophetic vision born of his own experience. Reaching to the heart of the `German question,' the controversies surrounding Heine have been as intense since his death as they were in his own lifetime, often serving as an acid test for important questions of national and social consciousness. This new volume of essays by scholars from Germany, Britain, Canada, and the United States offers new critical insights on key recurring issues in his work: the symbiosis of German and Jewish culture; emerging nationalism among the European peoples; critical views of Romanticism and modern philosophy; Europeanculture on the threshold to modernity; irony, wit, and self-critique as requisite elements of a modern aesthetic; changing views on teleology and the dialectics of history; and final thoughts and reconsiderations from his last, prolonged years in a sickbed. Contributors: Michael Perraudin, Paul Peters, Roger F. Cook, Willi Goetschel, Gerhard Hoehn, Paul Reitter, Robert C. Holub, Jeffrey Grossman, Anthony Phelan, Joseph A. Kruse, and George F. Peters. Roger F. Cook is professor of German at the University of Missouri, Columbia.